Late presentation of new HIV diagnosis

Elizabeth Crock: HIV Clinical Nurse Consultant, Nurse Practitioner, Bolton Clarke HIV Program, Melbourne 
Jayne Howard: HIV Clinical Nurse Consultant, Melbourne Sexual Health Centre, Melbourne


An estimated 36% of human immunodeficiency virus (HIV) diagnoses in Australia in 2017 were made late, defined as a diagnosis with a CD4 T-lymphocyte (CD4) count of less than 350 cells/µL, and approximately 22.5% of these were advanced infections, defined as having a CD4 count of less than 200 cells/µL[1].  The proportion of people diagnosed late in Australia is higher amongst people born in Central America, Sub-Saharan Africa and South East Asia than amongst those born in Australia, and is also higher amongst people who report heterosexual sex as their HIV risk exposure, men over 50 with male to male sex as their risk exposure, and men with bisexual sex as their risk.[2].

People diagnosed late (sometimes referred to as 'late presenters') may learn of their HIV status after being diagnosed with an opportunistic illness or infection such as Pneumocystis jiroveciipneumonia or central nervous system infections such as cerebral Toxoplasmosis gondii infection.[3] [4] (see also Clinical manifestations of HIV disease). They are more likely to require intensive care support if hospitalised, experience lengthy hospitalisation and have an increased risk of acquired immune deficiency syndrome (AIDS) or death particularly in the first year after diagnosis.[5] [6] [7] Lengthy hospitalisation can leave the patient fatigued, deconditioned and psychologically vulnerable. When starting HIV therapy, those who have been diagnosed late generally experience a longer time to immune reconstitution, are at prolonged risk of opportunistic infections and may also experience immune reconstitution inflammatory syndrome (IRIS).[8]

Early HIV diagnosis and treatment, on the other hand, offers benefits including reduced morbidity and mortality, avoidance of inpatient care, prevention of HIV transmission and better quality of life through appropriate treatment, care and support.[9] Nurses working in a wide range of settings - sexual health, viral hepatitis and HIV, primary care, community health, the drug and alcohol sector and homelessness services - can have an important role to play in increasing awareness and access to HIV testing for vulnerable groups and in promoting HIV testing with appropriate pretest education to avoid late diagnoses.

Strategies are in place in Australia to promote early diagnosis and treatment initiation. These include HIV testing during antenatal screening[10] and regular sexually transmissible infection (STI) screening for men who have sex with men.[11] However, there are gaps in reaching those who may not perceive themselves as being at risk of HIV infection: for example, older adults, women and heterosexual males. Nurses working in community health and primary care can assess risk and offer testing for HIV infection in individuals who present for general age-related medical examinations such as women attending for cervical cancer screening (Pap tests) or those seeking reproductive health services and advice. Nurses involved in the development of Medicare-funded care plans can introduce questioning around relationships and sexual health, especially in older adults disclosing risk behaviours and those with unexplained illnesses.[12]